Fillable Vha Form 10-7959a - Champva Claim Form printable pdf download

OMB Number: 2900-0219

Est. Burden: 10 minutes

CHAMPVA Claim Form

VA Health Administration Center

CHAMPVA

PO Box 469064

Denver CO 80246-9064

1-800-733-8387

Attention: After reviewing the following information, complete the form in its entirety (print or type only) and return with the

required documentation.

Claim form usage: This form is to be completed by the patient, sponsor, or guardian and is mandatory for all beneficiary claims. This claim

form is NOT to be used for provider submitted claims.

Other health insurance (OHI): If OHI exists, attach OHI’s Explanation of Benefits (EOB) to the provider’s itemized billing statement(s).

Dates of service and provider charges on EOB must match billing statements.

Timely filing requirement: Claims must be received no later than one year after the date of service or, in the case of inpatient care, within

one year of the discharge date.

Itemized billing statements: An itemized statement must be attached and contain:

• patient name, date of birth, and CHAMPVA Identification Card (ID-Card) Member Number (same as patient’s Social Security number);

• provider name, degree, tax identification number (TIN), address and telephone number; and

• service dates, itemized charges and appropriate procedure/diagnosis codes for each service (i.e. CPT-4, HCPCS, and ICD-9-CM

codes), including narrative descriptions. Pharmacy claims are to include name, quantity, strength, and NDC of each drug.

Section I - Patient Information

Last Name (this is a mandatory field)

First Name (this is a mandatory field)

CHAMPVA Member Number (this is a mandatory field)

Street Address

Date of Birth (mm/dd/yyyy)

Check if new

City

State

ZIP Code

Telephone Number (include area code)

Section II - Other Health Insurance (OHI) Information

By law, other coverage must be reported. Except for CHAMPVA supplemental policies, CHAMPVA is always the secondary payer.

If more space is needed, please continue in the same format on a separate sheet.

• Was treatment for a work-related injury or

Name of Other Health Insurance (OHI)

condition?

Yes

• Was treatment for an injury or accident

outside of work?

Yes

OHI Policy Number

OHI Telephone Number (include area code)

• Is patient covered by other primary health

insurance to include coverage through a

family member (supplemental or

secondary insurance excluded)?

Name of Other Health Insurance (OHI)

Yes (check type below and provide

coverage information on the right)

employer sponsored (group)

private (non group)

OHI Policy Number

OHI Telephone Number (include area code)

Medicare (Part A or B)

other

(specify)

no (proceed to Section III)

Section III - Sponsor Information

Last Name

First Name

CHAMPVA Member Number (this is a mandatory field)

Section IV - Claimant Certification

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious, or fraudulent statements or claims.

I certify that the above information and attachments are correct

Signature (type if electronic)

Date

and represent actual services, dates, and fees charged. (Sign and

date on right.) If certification is signed by a person other than the

patient, complete the information the signature and date.

Relationship to Patient

Last Name

First Name

Street Address

City

State

ZIP Code

Telephone Number (include area code)

VA FORM

10-7959a

MAY 2010

Vha Form 10-7959a - Champva Claim Form

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